Assessment and Management of Patients with Diabetes Mellitus in the Dental Office

Diabetes mellitus is a serious chronic disease that affects many dental patients. Dental professionals have the potential and responsibility to assume an active role in the early identification, assessment, and management of their patients who present with or are at risk of developing diabetes. Close maintenance, meticulous monitoring of individual patient needs, and close collaboration with other health care professionals involved in the care will enable better control of the oral complications of diabetes and contribute to the better management of the patient’s overall health status.

  • Dental professionals have the potential and the responsibility to assume an active role in the early identification, assessment, and management of their patients who present with or are at risk of developing diabetes.

  • Periodontal prevention and intervention are imperative, but periodontal therapy may provide challenges. Close maintenance, meticulous monitoring of the individual patient needs at any given time, and close collaboration with other health care professionals involved in the patient’s care will enable better control of the oral complications of diabetes and contribute to better management of the patient’s overall health status.

  • The time is right for implementing interprofessional education strategies in medical and dental training aiming to improve collaboration in the care of patients with diabetes.

Key Points

Diabetes mellitus

Diabetes mellitus represents a group of common, chronic metabolic disorders characterized by abnormal glucose metabolism, caused by a defect in insulin secretion, insulin action, or both. Two major types of diabetes exist: type 1 and type 2. The latter type is far more prevalent, affecting 85% to 90% of the diabetic population.

Diabetes constitutes a serious public health concern worldwide; it requires lifelong care, leads to serious complications and premature death, and remains incurable. Globally, the number of adults with diabetes was estimated at 366 million for 2011 and is expected to rise to 552 million in 2030. According to estimates in the United States for 2010, diabetes mellitus affects 8.3% of its population (approximately 25.8 million people); among those 65 years of age and older, the prevalence is much higher (estimated at 26.9%).

Hyperglycemia, the hallmark of both main types of diabetes, is associated with a range of acute and chronic disabling or life-threatening complications and can eventually affect all tissues and organs in the body, including the oral cavity. As a result, diabetes is relevant to all health care professionals, and the importance of prevention, early diagnosis, and proper treatment of affected individuals cannot be overstated.

Oral complications of diabetes mellitus

Periodontal Disease and the Two-Way Association

The effects of diabetes on the periodontal status of affected individuals have been extensively studied over many decades, and several reviews on the topic have been published. In sum, among all systemic conditions, diabetes is the strongest risk factor for periodontitis, leading to increased prevalence, severity, and progression of the disease. Contrary to prior belief, diabetes can contribute to periodontal destruction even early in life, with recent comprehensive studies suggesting that diabetes significantly contributes to increased attachment loss in youth even after adjusting for common confounding factors.

Importantly, the relationship of diabetes mellitus and periodontal disease seems to be bidirectional, with accumulating evidence suggesting that periodontal infections may adversely affect metabolic control and other health outcomes in patients with diabetes. Several longitudinal studies have shown that severe periodontitis at baseline, when compared with periodontal health or mild periodontitis, can lead to increased levels of hemoglobin A1c (HbA1c), increased mortality from cardiovascular outcomes, and more renal and vascular complications in patients with diabetes at follow-up. Some evidence shows that severe periodontitis can also lead to incident diabetes, although this concept has been challenged. These effects are believed to be mediated through the proinflammatory mediators produced in the highly vascular periodontal tissue when periodontitis is present, which can act as insulin antagonists. Studies of periodontal treatment in patients with diabetes with systemic outcomes provide further support of these potential effects. Most of the available studies to date included small numbers of subjects and approached therapy with various protocols, but evidence from recent meta-analyses of treatment studies suggests that periodontal therapy will improve oral health for patients with diabetes, and this may also result in modest improvement in levels of metabolic control.

Other Oral Complications

In addition to periodontal diseases, dental caries, burning mouth syndrome, Candida infection, salivary dysfunction/xerostomia, taste and other neurosensory disorders, altered tooth eruption and benign parotid hypertrophy have all been reported to be associated with diabetes.

Evidence suggests that tooth eruption in the late mixed dentition period is accelerated in youth with diabetes compared with those without. On the other end of the age spectrum, some of the more recent findings in older adults include the following: (1) coronal caries seem comparable, but the prevalence of root caries is higher in patients with diabetes ; (2) salivary flow is comparable, but the effects of xerogenic medications are more pronounced in patients with diabetes than controls ; and (3) for edentulous patients with diabetes, a greater prevalence of burning mouth syndrome, dry mouth, angular cheilitis, and glossitis is observed.

These disorders have received less attention than periodontitis in the literature, but given the increasing prevalence of diabetes in both children and older adults and the aging of the population, several patients may present with a diabetes-related oral complaint and, thus, awareness of these potential oral disorders in patients with diabetes is important for dental practitioners.

Oral complications of diabetes mellitus

Periodontal Disease and the Two-Way Association

The effects of diabetes on the periodontal status of affected individuals have been extensively studied over many decades, and several reviews on the topic have been published. In sum, among all systemic conditions, diabetes is the strongest risk factor for periodontitis, leading to increased prevalence, severity, and progression of the disease. Contrary to prior belief, diabetes can contribute to periodontal destruction even early in life, with recent comprehensive studies suggesting that diabetes significantly contributes to increased attachment loss in youth even after adjusting for common confounding factors.

Importantly, the relationship of diabetes mellitus and periodontal disease seems to be bidirectional, with accumulating evidence suggesting that periodontal infections may adversely affect metabolic control and other health outcomes in patients with diabetes. Several longitudinal studies have shown that severe periodontitis at baseline, when compared with periodontal health or mild periodontitis, can lead to increased levels of hemoglobin A1c (HbA1c), increased mortality from cardiovascular outcomes, and more renal and vascular complications in patients with diabetes at follow-up. Some evidence shows that severe periodontitis can also lead to incident diabetes, although this concept has been challenged. These effects are believed to be mediated through the proinflammatory mediators produced in the highly vascular periodontal tissue when periodontitis is present, which can act as insulin antagonists. Studies of periodontal treatment in patients with diabetes with systemic outcomes provide further support of these potential effects. Most of the available studies to date included small numbers of subjects and approached therapy with various protocols, but evidence from recent meta-analyses of treatment studies suggests that periodontal therapy will improve oral health for patients with diabetes, and this may also result in modest improvement in levels of metabolic control.

Other Oral Complications

In addition to periodontal diseases, dental caries, burning mouth syndrome, Candida infection, salivary dysfunction/xerostomia, taste and other neurosensory disorders, altered tooth eruption and benign parotid hypertrophy have all been reported to be associated with diabetes.

Evidence suggests that tooth eruption in the late mixed dentition period is accelerated in youth with diabetes compared with those without. On the other end of the age spectrum, some of the more recent findings in older adults include the following: (1) coronal caries seem comparable, but the prevalence of root caries is higher in patients with diabetes ; (2) salivary flow is comparable, but the effects of xerogenic medications are more pronounced in patients with diabetes than controls ; and (3) for edentulous patients with diabetes, a greater prevalence of burning mouth syndrome, dry mouth, angular cheilitis, and glossitis is observed.

These disorders have received less attention than periodontitis in the literature, but given the increasing prevalence of diabetes in both children and older adults and the aging of the population, several patients may present with a diabetes-related oral complaint and, thus, awareness of these potential oral disorders in patients with diabetes is important for dental practitioners.

Patient and health care provider awareness of the link between diabetes and oral health

The variety of oral complications associated with diabetes emphasizes their importance for patients and the medical and dental professionals who care for them. Still, studies suggest relatively low awareness of these issues among patients and professionals alike.

According to Tomar and Lester, patients with diabetes were less likely to visit a dentist in the preceding 12 months, and the leading reason for not seeing a dentist was “lack of perceived need.” Moore and colleagues also reported that only 18% of patients with diabetes were aware of its effects on oral health and 52% reported cost as the reason for avoiding routine dental visits. Subsequent studies in the UnitedStates, Sweden, the United Kingdom, and Jordan suggested similar trends.

With regard to medical providers, the evidence to date suggests that physicians and nurses do not receive adequate training in oral health, rarely advise patients on aspects of oral health, and are not comfortable performing a simple periodontal examination on their at-risk patients. A more recent survey of North Carolina endocrinologists and internists (response rate: 34%) showed that physicians believe an association exists between periodontitis and diabetes. However, most are not aware of the studies that link the conditions and believe that physicians should receive more education about periodontal diseases and how to screen for them.

Dental professionals are largely aware of the link between diabetes and oral health, because related material has been taught in dental and dental hygiene schools for many decades, but unfortunately this knowledge does not seem to fully translate into practice. Some years ago, dentists’ performance of activities related to the management of patients with diabetes was investigated via a mail survey of a representative sample of randomly selected general practitioners and periodontists in the northeast United States (response rate: 80% and 73%, respectively). Results showed that general dentists are more willing to manage the care of patients with diabetes on an assessing and advising basis than on a more active management basis. With respect to periodontists, results were similar, although overall periodontists performed active management behaviors more frequently than general dentists. When assessed internationally in a representative sample of general dentists in New Zealand, a similar pattern of involvement emerged. Since these first reports documenting the extent of dentists’ practice activities with respect to the management of patients with diabetes, and with increasing evidence of the oral-systemic link, subsequent studies have suggested that attitudes toward active management have somewhat improved.

Assessment and management of patients with diabetes mellitus by dental professionals

The information reviewed earlier strongly suggests a great need, and responsibility, for dental professionals to assume an active role in the education and management of patients with diabetes. Encouragingly, several characteristics of dental practice are consistent with dentists assuming this role: they treat large numbers of patients each year, and often provide primary and preventive care that is nonemergent in nature. Even patients who attend dental offices for “problem-oriented” visits often segue into preventive programs and regular examination and hygiene visits after completion of active treatment, and are seen at regular recall intervals. This practice allows for certain conditions to be followed over time and provides an opportunity for long-term patient contact and reinforcement.

Diagnosis and treatment of diabetes mellitus are the responsibility of the physician. However, as outlined in Box 1 , dental professionals have a responsibility to seek to identify patients at risk who may remain uninformed and undiagnosed; evaluate signs and symptoms indicative of poor metabolic control in patients with known diabetes; advise identified patients in both groups about their condition and refer them to a physician for proper evaluation and treatment; and provide safe and predictable oral care for all of these patients, as needed.

Box 1

  • Know the major type 2 diabetes risk factors and seek to identify dental patients at risk who may remain unidentified/undiagnosed

  • Evaluate signs and symptoms indicative of poor metabolic control in patients with known diabetes

  • Inform identified patients in both groups about their condition and advise on lifestyle modifications

  • Refer patients in both groups to a physician for proper evaluation and treatment

  • Provide safe and predictable oral/dental care, as needed

Responsibilities of dental professionals toward patients at risk for, or with known, diabetes mellitus

Patient with Unknown Diabetes or at Risk for Developing Diabetes

Currently, an estimated one-quarter of patients affected by diabetes in the United States remain undiagnosed. Because symptoms in type 2 diabetes develop gradually and are not specific to the disease, the diagnosis is frequently not made until complications appear. The delay in clinical diagnosis is substantial and involves a period of about 9 to 12 years. Type 1 diabetes is considered not preventable, but type 2 diabetes can be prevented in many cases, and awareness of its major risk factors (outlined in Box 2 ), many of which are modifiable, is important. Further, prediabetes (a condition in which blood glucose levels are higher than normal, but not high enough for a diagnosis of diabetes) affects approximately 35% of the U.S. adult population. People with prediabetes have a strong risk for developing type 2 diabetes and are already at an increased risk for heart disease, stroke, and microvascular diseases. Strong evidence indicates that people with prediabetes who lose weight and increase their physical activity can prevent or delay diabetes and even return their blood glucose levels to normal. As with diabetes, the paramount challenge is early detection and intervention, and all health care providers can contribute to improved patient awareness and appropriate patient management.

Box 2

  • Age >40 years (or younger for high-risk race/ethnicity individuals)

  • High-risk race/ethnicity (African American, Hispanic/Latino, Alaska Native, American Indian, Asian American, or Pacific Islander)

  • Family history of diabetes (1st- or 2nd-degree relative)

  • Habitual physical inactivity

  • Overweight (body mass index ≥25 kg/m 2 for most but not all ethnic groups)

  • Hypertension (blood pressure ≥140/90 mm Hg)

  • Dyslipidemia (high-density lipoprotein cholesterol ≤35 mg/dL or triglycerides ≥250 mg/dL

  • Prediabetes, impaired glucose tolerance, or impaired fasting glucose

  • History of vascular disease or other diabetes-associated conditions

  • For women

    • Delivery of infant >9 lb

    • History of gestational diabetes

    • Polycystic ovary syndrome

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Oct 29, 2016 | Posted by in General Dentistry | Comments Off on Assessment and Management of Patients with Diabetes Mellitus in the Dental Office
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